Print Name of First Person in Charge of Funeral (see Exceptions, bottom of Page 1)
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Print Above Person's Full Address
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Above Person's Phone Number
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(Note: It is not required to name a successor representative(s), but it is encouraged)
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Second Person in Charge (same exceptions on page 1)
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Second Person's Full Address
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Second Person's Phone Number
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Third Person in Charge (same exceptions on page 1)
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Third Person's Full Address
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Third Person's Phone Number
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Simple Cremation through Milwaukee Cremations.
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www.milwaukeecremate.com
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Simple and secure credit card payment at www.milwaukeecremate.com
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Date
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Month and Year (this is the date YOU are signing)
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YOUR Signature (MUST be signed in front of Notary OR Two Witnesses)
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Date
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Month and Year (date of signature of First Person in Charge (below);
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Signature of First Person in Charge (No notary or witnesses required)
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does not need to match date you signed)
Authorization for Final Disposition F-00086 (05/10)
Page 5 of 5
I hereby accept appointment as successor representative for the control of final disposition of the declarant's remains.
Signed this ______ day of _______________ _(Day) (Month and Year)
Signature of first successor representative ____________________ _
Signed this ______ day of _______________ _(Day) (Month and Year)
Signature of second successor representative __________________ _
I attest that the declarant signed or acknowledged this authorization for final disposition in my presence and that the declarant appears to be of sound mind and not subject to duress, fraud, or undue influence. I further attest that I am not the representative or the successor representative appointed under this document that I am aged at least 18, and that I am not related to the declarant by blood, marriage, or adoption.
1 st Witness (print name) __________________________ _
Signature _______________________________ _
Address ---------------------------------
Date (Month, Day, Year) ________________________ _
Date (Month, Day, Year) _________________________ _
In lieu of two witnesses signing this form, the declarant may sign it in the presence of a notary public.
State of Wisconsin, County of ________________________ _
On (date) ___________________ , before me personally appeared
(name of declarant) _____________________ known to me or satisfactorily proven to be the individual whose name is specified in this document as the declarant and who has acknowledged that he or she executed the document for the purposes expressed in it. I attest that the declarant appears to be of sound mind and not subject to duress, fraud, or undue influence.
Notary Public Name: ___________ Signature _____________ _
My commission expires (date) __________ _ (Seal)
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Date
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Signature of Second Person in Charge (No notary or witnesses
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required)
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Date
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Month and Year (date of signature of Third Person in Charge (below);
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Signature of Third Person in Charge (No notary or witnesses
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required)
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First Witness Printed Name (cannot be a relative or anyone named on this form)
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First Witness Signature
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First Witness Address
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Date First Witness Signed (must match date you signed)
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Second Witness Printed Name (cannot be a relative or anyone named on this form)
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Second Witness Signature
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Second Witness Address
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Date Second Witness Signed (must match date you signed)
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[indicate County where signed]
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Date (must be same date you signed)
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Your Name
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Notary's Name
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Notary's Signature
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Date Notary Commission Expires
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** NOTE: Your signature must be EITHER notarized OR witnessed by two witnesses **
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Month and Year (date of signature of Second Person in Charge (below);
